Validation of the Child PTSD Symptom Scale (CPSS) in Spanish Adolescents

Elena R. Serrano-Ibáñez, Gema T. Ruiz-Párraga, Rosa Esteve, Carmen Ramírez-Maestre, and Alicia E. López-Martínez

Validation of the Child PTSD Symptom Scale (CPSS) in Spanish adolescents

Elena R. Serrano-Ibáñez, Gema T. Ruiz-Párraga, Rosa Esteve, Carmen Ramírez-Maestre, and Alicia E. López-Martínez Universidad de Málaga

Abstract Resumen

Background: One of the most frequently used instruments to assess Validación española de la Child PTSD Symptom Scale (CPSS) en posttraumatic stress in children and adolescents is the Child PTSD adolescentes. Antecedentes: la Child PTSD Symptom Scale es uno de Symptom Scale. However, there has been limited evaluation of its construct los cuestionarios más utilizados para evaluar el estrés postraumático en validity in the Spanish language despite Spanish being one of the most niños y adolescentes. Sin embargo, es escasa la investigación acerca de widely spoken languages in the world. Objective: To provide data on the la validez de constructo de la versión en español de este instrumento, psychometric properties of the CPSS in a sample of Spanish adolescents, a pesar de tratarse de uno de los idiomas más hablados en el mundo. to establish the internal consistency of the measure, and to examine its Objetivo: validar la versión española de esta escala en una muestra criterion validity. Method: The participants were 339 adolescents (172 de adolescentes. Método: los participantes fueron 339 adolescentes boys and 167 girls, mean age 13.95) exposed to peer violence during the (172 varones y 167 mujeres, con una media de edad de 13,95 años) previous year. Results: Confi rmatory factor analysis demonstrated a good que cumplían los criterios de haber sufrido violencia por parte de fi t to the four-factor dysphoria model. The alpha reliabilities for the overall sus iguales durante el año previo al estudio. Resultados: el análisis measure and its subscales were suitable. Discussion: The Spanish version confi rmatorio mostró un buen ajuste del modelo de cuatro factores of the scale has sound psychometric properties with good reliability and de disforia. Los coefi cientes de fi abilidad para la medida global y validity. Moreover, it integrates the four-factor structure corresponding to sus subescalas fueron adecuados. Discusión: la versión española la the dimensions of PTSD described in the DSM-V. escala presenta buenas propiedades psicométricas y una estructura Keywords: Peer abuse, Child PTSD Symptom Scale, spanish adolescents, factorial que se corresponde a los criterios para el trastorno de estrés factor structure, psychometric properties. postraumático del DSM-V. Palabras clave: abuso entre iguales, Child PTSD Symptom Scale, adolescentes españoles, estructura factorial, propiedades psicométricas.

A large number of children and adolescents are victims good psychometric proprieties to assess PTSD among adolescents of traumatic experiences, the most common being bullying, are needed. cyberbullying, and emotional, physical, and/or sexual abuse, One such instrument is the Child PTSD Symptom Scale including that perpetrated by peers. Posttraumatic stress disorder (CPSS) developed by Foa, Johnson, Feeny, and Treadwell (2001). (PTSD) is one of the most prevalent disorders among children and The CPSS is brief, easy to administer, available for free, and has adolescents who have experienced a traumatic event. A recent meta- great potential for research and clinical applications. It comprises analysis showed that 16% of children and adolescents exposed to a 17 items. The total symptom score and three symptom clusters of traumatic event subsequently developed PTSD (Alisic et al., 2014). the CPSS demonstrated suitable internal consistency, as well as The Diagnostic and statistical manual of mental disorders- 5th high test–retest reliability for both the total score and the three edition ([DSM-V] American Psychiatric Association [APA], 2013) subscales (intrusion, avoidance, and arousal symptoms) (Foa et adds four new clusters of symptoms to this disorder: intrusion, al., 2001). The CPSS has demonstrated very good convergent and avoidance, negative alterations in cognition and mood, and some support for its discriminant validity has also been obtained alterations in arousal and reactivity. Therefore, instruments with (Nixon, Sterk, & Pearce, 2012; Stewart, Ebesutani, Drescher, & Young, 2015). Cross-cultural translations of the scale have shown good reliability and validity, including Hebrew (Rachamim et Received: April 18, 2017 • Accepted: September 13, 2017 al., 2011) and Turkish versions (Kadak, Boysan, Ceylan, & Çeri, Corresponding author: Alicia E. López-Martínez 2014). In spite of this, there has been limited evaluation of the Facultad de Psicología instrument’s construct validity and its psychometric properties in Universidad de Málaga 29071 Málaga (Spain) the Spanish language, although Spanish is one of the most widely e-mail: [email protected] spoken language in the world.

130 Validation of the Child PTSD Symptom Scale (CPSS) in Spanish adolescents

Several studies aimed at analyzing the dimensions of PTSD Adolescent Victimization through Mobile Phone and Internet have been performed and a meta-analysis demonstrated that the Scale (CIBVIC; Buelga, Cava, & Musitu, 2012). This questionnaire dysphoria model outperformed the numbing model in almost all includes 8 items refer to mobile phone cyberbullying and 10 items subsamples (Yufi k & Simms, 2010). However, in the study by to internet cyberbullying experienced over the previous year. The Helpman et al. (2014) based on responses to the CPSS fi ndings items are rated on a 4-point Likert-type scale. Cronbach’s alpha demonstrated that the model that best fi t the data was the four-factor for this questionnaire was 0.81. numbing model, compared to the three-factor model (intrusion, Self-reported Victimization Questionnaire (Cava, Musitu, & avoidance, and arousal symptoms), a three-factor dysphoria model Murgui, 2007). The questionnaire uses a 20-item scale are rated on a (intrusion, dysphoria, and arousal), and a four-factor dysphoria 4-point Likert-type on which participants indicate how often during model (intrusion, avoidance, dysphoria, and arousal). t he last school yea r t hey have exp er ience d 2 0 vict i m i zi ng exp er iences. Gudiño and Rindlaub (2014) examined the CPSS and its Ten items refer to peer overt victimization (physical and/or verbal psychometric properties in a sample of Latino students who were assault), and 10 items refer to peer relational victimization (social exposed to chronically elevated levels of community violence. ostracism). Cronbach’s alpha for this questionnaire was 0.90. Their results supported a three-factor model (re-experiencing/ Confl ict in Adolescent Dating Relationships Inventory intrusion, avoidance, and arousal), but did not support the four- (Spanish version, Fernández-Fuertes, Fuertes, & Pulido, 2006). factor numbing or four-factor dysphoria models (King, Leskin, The brief 34-item scale was used to assess fi ve types of intimate King, & Weathers, 1998; Simms, Watson, & Doebbeling, 2002, violence in adolescent dating relationships: sexual abuse, relational respectively). High internal consistence was obtained for the total abuse, verbal or emotional abuse, threatening behaviour, and scale (α = .92). Meyer, Gold, Beas, Young, and Kassam-Adams physical abuse. The items are rated on a 4-point Likert-type scale. (2014) also tested the psychometric properties of the CPSS in Cronbach’s alpha for this questionnaire was 0.89. Latino children residing in USA. Compared to the Spanish version, Emotional Quotient Inventory Youth Version (Spanish version, the English version had a better fi t to the data for all the models López-Zafra, Pulido, & Berrios, 2014). The EQ-i:YV is a self-report of the PTSD symptoms structure. The four-factor numbing and measure that assesses the level of emotional and social functioning dysphoria models had the best fi t for both versions. Nevertheless, in children and adolescents of 7 to 17 years of age. This study used the fi t indices were quite modest, particularly for the Spanish the 8 items that measure general mood. The instrument uses a model (Meyer et al., 2014), which indicates that this version of the 5-point scale. Cronbach’s alpha for this questionnaire was 0.83. CPSS lacks construct validity. Satisfaction with Life Scale (Spanish version, Atienza, Pons, The fi rst aim of the present study was to provide data on the Balaguer, & García-Merita, 2000). This questionnaire was factor structure of the CPSS in a sample of Spanish adolescents developed as a measure of subjective global life satisfaction and who had experienced peer abuse (i.e., bullying, cyberbullying, well-being. It includes 5 items rated on a 5-point Likert-type scale and/or dating violence) during the previous year. Five models were ranging from 1 (totally disagree) to 5 (totally agree). Cronbach’s examined: a single-factor model, the DSM-IV-TR three-factor alpha for this questionnaire was 0.74. model, the three-factor dysphoria model, the four-factor numbing Kessler Psychological Distress Scale (Spanish version, Vargas, model, and the four-factor dysphoria model corresponding to Villamil, Rodríguez, Pérez, & Cortés, 2011). The questionnaire the dimensions of PTSD described in the DSM-V (APA, 2013). includes 10 items that refer to the level of anxiety and depressive The second aim was to establish the internal consistency of the symptoms experienced during the last month. The items are rated measure and to examine its criterion validity. on a 5-point Likert-type scale ranging from 1 (never) to 5 (always). Cronbach’s alpha for this questionnaire was 0.84. Method KIDSCREEN-10 Index (Spanish version, Erhart et al., 2009). It assesses perceived health-related quality of life. The 10 items Participants are rated on a 5-point scale ranging from 1 (none of the time) to 5 (all of the time). It also includes a question on perceived health. The original sample comprised 699 high-school students from Cronbach’s alpha for this questionnaire was 0.75. Málaga (Spain). 49 participants were eliminated due to incomplete Child PTSD Symptom Scale (CPSS; Foa, Johnson, Feeny, & responses and 274 participants were also eliminated because they Treadwell, 2001). Comprises 17 items corresponding to PTSD did not fulfi l the criterion of having been exposed to peer violence symptoms and is designed for use with children aged 8-18 years. during the previous year. Therefore, the fi nal sample comprised Participants rate how often each symptom has occurred in the past 339 adolescents (172 boys and 167 girls; mean age 13.95 years; month on a 4-point scale ranging from 0 (not at all) to 3 (5 or SD = 1.29). more times a week). The total score is calculated by summing all The participating students refl ected the general characteristics items (see below for further details). Both English and Spanish of children attending urban secondary schools in Andalusia versions are available. The Spanish version was used in the current (Spain). Most students (85.3%) were between 13 and 17 years of study, although some items were slightly reworded to facilitate age. Of the total sample, 94.7% were living with their families understanding by Spanish populations. A list of the items in the (with both or one of their parents, and with their brothers/sisters, questionnaire can be requested from the authors. if applicable). Procedure Instruments The current study was part of a larger school-based study of All participants were requested to give written information traumatic stress events in adolescents, which received institutional regarding their age, gender, educational level, and school year. review board approval at the University of Málaga (Spain).

131 Elena R. Serrano-Ibáñez, Gema T. Ruiz-Párraga, Rosa Esteve, Carmen Ramírez-Maestre, and Alicia E. López-Martínez

Teachers, parents, and students were informed about the aim of scores and general mood and happiness, and the interaction of the research before they agreed to participate. The protocol for the CPSS scores and life satisfaction, on psychological distress the study was approved by the Institutional Review Board of the and health-related quality of life. A series of standardized product school. After parental consent had been obtained and prior to variables were then created to represent interactions between the data collection, children voluntarily agreed to participate in the CPSS scores and psychological distress, and between the CPSS study. Assessments were conducted in small groups of 20 to 25 scores and health-related quality of life. Interaction effects were students and a single trained clinical psychologist controlled the only analysed in those cases in which the predictors signifi cantly procedure. All tests followed the authors’ instructions on use of predicted the outcome variables considered in the analyses. the instruments and were conducted during school hours. Each Internal consistency was calculated using Cronbach’s α participant anonymously completed a battery of instruments, coeffi cient for the total score and for the score of each factor. which were always presented in the same order. To assess the criterion validity of the CPSS, associations were analysed between the CPSS global score and general mood and Data analysis happiness, life satisfaction, psychological distress, and health- related quality of life, while controlling for sex. Univariate and multivariate distributions were analysed. Inspection of Mahalanobis d2 values indicated that there were no Results multivariate outliers in the sample. Little’s MCAR test was used and missing values were replaced by using the multiple imputation Descriptive and preliminary analyses method. Means, standard deviations, and correlations were calculated Preliminary examinations of the data revealed that the overall for each variable. To test the factor structure of the CPSS, a level of missing data was 4.73%. Missing values were imputed after confi rmatory factor analysis (CFA) was performed. Maximum fi nding no statistically reliable deviation from randomness using likelihood estimation was used for the analyses. To test model fi t, Little’s MCAR test, χ2 (119) = 90.133, p = 0.07. The remaining a chi-squared statistic was used as an absolute index of goodness analyses were conducted on the imputed data set. of fi t. The model fi t was considered to be satisfactory according to The types of abuse reported by the participants were as follows: the following criteria (Ullman, 2006): a) the adjusted goodness- cyberbullying by mobile phone (49.4%), by internet (41.2%), or of-fi t-index (AGFI) and the comparative fi t index (CFI) with by both (32.5%), bullying (11.2%), bullying and some type of values of .90 indicating a good fi t; b) the root mean square error cyberbullying (28.9%), dating violence (36.3%), or all these types of approximation (RMSEA) and the standardized root mean of abuse (10.0%). As shown in Table 1, score ranges, means and square residual (SRMR) were less than .08. In all CFA analyses, standard deviations for each variable were calculated. Table 1 also correlations between errors were constrained to zero, items were shows the partial correlations between the measures considered in constrained to load on only one factor, and factors were free to the study while controlling for sex. Medium signifi cant negative correlate. effect size correlations were found between the scores on the CPSS Comparisons between nested models were conducted using and general mood and happiness, life satisfaction, and health- the S-B χ2 test (Satorra & Bentler, 2001). Comparisons between related quality of life. A medium signifi cant and positive effect size non-nested models were conducted by comparing the Akaike was found between the CPSS and global psychological distress. information criterion (AIC). Firstly, we assessed the model fi t of Girls had higher scores than boys on the CPSS and reported each of the fi ve models examined. We then compared the nested greater psychological distress, and had lower scores on happiness models followed by the non-nested models. Once the best-fi tting and perceived health-related quality of life. The mean CPSS model was found, it was modifi ed by modelling the error terms total score for the whole sample was 29.19 (SD = 9.19), and that were correlated and the model fi t was assessed again. 53.4% of participants met or exceeded the clinical cutoff of 11 A series of moderated multiple regression analysis were then established by Foa et al. (2001). When a cutoff score of 15 was performed to analyse the effects of the interaction of the CPSS used, as recommended by the International Society of Traumatic

Table 1 Descriptive statistics and partial correlations between measures while controlling for sex

Total sample Boys Girls (N = 339) (n = 172) (n = 167)

Variable Range Mean SD Mean SD Mean Mean Partial correlations

Min Max 2345

1. CPSS 17 63 29.19 9.19 27.55 8.23 30.89 9.82 -.25 -.23 .46 -.24 2. EQ-i: YV 12 40 29.73 5.30 30.80 4.77 28.63 5.60 1 .55 -.32 .61 3. SWLS 5 20 15.31 3.23 15.56 3.13 15.05 3.32 1 -.33 .58 4. K10 11 47 27.38 6.89 25.77 6.70 29.03 6.43 1 -.34 5. KIDSCREEN-10 23 49 38.23 5.12 39.16 4.62 37.28 5.44 1

Note: CPSS = Child PTSD Symptom Scale; EQ-i: YV = Emotional Quotient Inventory Youth Version; SWLS = Satisfaction with Life Scale; K10 = Kessler Psychological Distress Scale. All correlations are signiﬁ cant at p < .000

132 Validation of the Child PTSD Symptom Scale (CPSS) in Spanish adolescents

Stress Studies (2012), 34.8% of participants met the criteria for a The AIC goodness-of-fi t index was then used to compare the diagnosis of PTSD. When a clinical cutoff score of 16 or greater remaining models. Table 2 shows that the four-factor dysphoria was used, recommended by Nixon et al. (2013), 30.9% of the model had the lowest value and the best fi t. The results of participants were identifi ed as having probable PTSD. the evaluation of the fi nal model indicated an adequate fi t, χ2 (108) = 306,43, p = .000, NFI = .92, CFI = .95, RMSEA = .06. Factor structure This final model included four factors: intrusion (items 1-5), avoidance (items 6-8), dysphoria (items 9-15), and arousal Model fi t was assessed for each model (see Table 2). The nested (items 16 and 17) (see Figure 1). Factor loadings were equal or models were then compared (i.e., the four-factor numbing model more than .51. and the three-factor model, as well as the four-factor dysphoria model and the three-factor dysphoria model). A significant Criterion validity difference was found between the four-factor numbing model and the three-factor model, χ2 (3) = 35.93, p < .000. The four-factor We analysed the effects of the interactions between the global numbing model, χ2 (113) = 317.00, provided a better fi t than the score of the CPSS and general mood and happiness, as well as three-factor model, χ2 (116) = 352.94. A signifi cant difference was the effects of the interactions between the global score on the found between the four-factor dysphoria model and the three- CPSS and life satisfaction, on psychological distress and health- factor dysphoria model, χ2 (3) = 42.45, p < .000. The four-factor related quality of life (see Table 3). Psychological distress was dysphoria model, χ2 (111) = 306.43, provided a better fi t than the signifi cantly predicted by general mood and happiness, and by three-factor dysphoria model, χ2 (116) = 323.86. the total CPSS score. The interaction between general mood and the CPSS score added signifi cant incremental variance, 1.8%, B = Table 2 .016, p = .003. General mood and CPSS score were signifi cantly Fit indices for confi rmatory factor analyses and independently associated with health-related quality of life, although no interaction effects were found. Life satisfaction and S-B AGFI RMSEA SRMR CFI AIC the global score on the CPSS signifi cantly and independently χ2 predicted psychological distress, although no interaction effects One-factor model 523.57 .77 .10 .06 .80 591.57 were found. Furthermore, life satisfaction and CPSS scores were DSM-IV three-factor 352.94 .85 .08 .05 .88 426.94 signifi cantly and independently associated with health-related model quality of life, but no interaction effects were found. Three-factor dysphoria 323.86 .87 .07 .04 .90 397.86 model Internal consistency Four-factor numbing 317.01 .87 .07 .04 .90 397.01 model The CPSS total symptom scale demonstrated high internal Four-factor dysphoria 306.43 .92 .06 .03 .95 390.43 model consistency with the full sample (α = .90). Internal consistency was moderate to good within the subscale symptom factors: α Note: S-B χ2 = Santorra-Bentler χ2 test; AGFI = adjusted goodness-of-fi t-index; RMSEA = = .80 on the re-experiencing/intrusion subscale, α = .70 on the root mean square error of approximation; SRMR = standardized root mean square residual; avoidance subscale, α = .83 on the dysphoria subscale, and α = .74 CFI = comparative fi t index; AIC = akaike information criterion on the arousal subscale.

1 2 3 45 6 78 9 1011121314151617

.66 .51 .60 .79 .74 .68 .63 .51 .58 .70 .67 .56 .62 .72 .61 .70 .83

Avoidance Arousal

Intrusion Dysphoria

.82 .81 .64

.72 .52

.54

Figure 1. Conﬁ rmatory factor analysis of the four-factor dysphoria model of the CPSS corresponding to the dimensions of PTSD described in the DSM-V

133 Elena R. Serrano-Ibáñez, Gema T. Ruiz-Párraga, Rosa Esteve, Carmen Ramírez-Maestre, and Alicia E. López-Martínez

The Spanish version of the CPSS had sound psychometric Table 3 Moderated multiple regression analyses properties with good reliability and validity. The total symptom scale exhibited high internal consistency and reliability for the Health-related quality Psychological distress subscales and was similar to the initial validation study by Foa of life et al. (2001) and subsequent psychometric analyses (Gillihan, Predictor variables β∆R2 R2 β∆R2 R2 Aderka, Conklin, Capaldi, & Foa, 2013; Gudiño & Rindlaub, 2014; Kadak et al., 2014; Meyer et al., 2014; Rachamim et al., General mood and happiness -.26* .61* .30 .40 2011; Stewart et al., 2015). Regarding criterion validity, the total CPSS .48* .16* -.13** .01** Interaction .15* .02* -.07 .00 symptom scale correlated with all the measures considered in the study. Nevertheless, no interaction effects were found between the Life satisfaction -.24* .55** .29 CPSS scores and general mood and happiness in the prediction CPSS .46* .17* -.15* .02** .35 of health-related quality of life. In addition, no interaction effects Interaction .08 .01 -.04 .00 were found between the CPSS scores and life satisfaction in the * p < 0.01; ** p < 0.05 prediction of psychological distress or health-related quality of life. Hence, higher scores on PTSD independently predicted psychological distress and health-related quality of life. The global Discussion score on the CPSS moderated the relationship between general mood and happiness and global psychological distress, which Although the CPSS is a widely used measure to assess PTSD suggests that this negative relationship was stronger when CPSS in young people, to the best of our knowledge this study is the fi rst scores were high. Thus, the results suggest that adolescents with to examine the factor structure and psychometric properties of higher scores on PTSD, as measured by the CPSS, would feel less the CPSS in a Spanish sample. The purpose was to determine the happy, more distressed, and have a poorer quality of life. factor structure of the Spanish version of the CPSS in a sample of This study has several limitations. Firstly, due to the logistic adolescents who had experienced peer abuse during the previous diffi culties arising from this study being part of a larger project, year. In addition, the internal consistency and criterion validity of the diagnostic utility of the CPSS was not assessed because of the questionnaire were examined. the lack of a diagnostic interview measure. The properties of The adolescents had been exposed to some type of peer abuse the Spanish version of the CPSS should be examined in clinical in a non-negligible percentage. Moreover, 30.9% of participants samples. Secondly, measurement invariance tests were not in this study met the criteria for a diagnosis of PTSD when conducted between the boys and girls because of the relatively considering the recommendations of the International Society of small sample size. Future studies should include a larger sample to Traumatic Stress Studies (2012), increasing up to 53.4% according examine whether the CPSS items are invariant across populations. to the clinical cutoff established by Foa et al. (2001). Thirdly, data were collected by self-report measures alone, which Confi rmatory factor analyses suggested that the fi ndings are likely introduced some shared method variance across all the best described by the four-factor dysphoria model. In fact, the assessment measures. Finally, the test-retest reliability of the models that have been most consistently replicated across studies CPSS was not analysed, which is an important aspect for future are the four-factor models of King et al. (1998) and Simms et al. research on its use in Spanish youth. (2002). Using the CPSS, Kassam-Adams, Marsac, and Cirilli Despite these limitations, this Spanish version of the CPSS (2010) found that both the numbing four-factor model and the provides clinicians and researchers with a valid and reliable measure dysphoria four-factor model had a good fi t in a sample of children of PTSD among Spanish adolescents. Moreover, it integrates the and adolescents who had experienced unintentional injury. In the four-factor structure corresponding to the dimensions of PTSD study by Meyer et al. (2014) the dysphoria four-factor model had a described in the DSM-V (APA, 2013). slightly better fit in the Spanish sample, which was also the case in the current study. Hukkelberg & Jensen (2011) also found that the Acknowledgements dysphoria four-factor model had the best fi t to the observed data. Overall, the results suggest that four dimensions defi ne PTSD in We thank Antonio J. Lechuga for his assistance in data youth samples, which is in line with proposals regarding adult data collection. The fi rst author received a grant from the Spanish (i.e., King et al., 1998; Simms et al., 2002). Ministry of Education, Culture, and Sports (FPU13/04928).

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